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Diabetes MCN Management of Diabetes Last updated: 28/06/2019 Approved by MSDTC: 26/06/2019 Risk with High Dose Steroids 2019 V1.0 Review due: 26/06/2021
MANAGEMENT OF DIABETES RISK WITH HIGH DOSE STEROIDS
Adapted from the Joint British Diabetes Societies (JBDS) for Inpatient Care ‘Management of Hyperglycaemia
and Steroid (Glucocorticoid) Therapy’ (2014) and NHS Lothian steroid guidance documents. The guidance is
designed for use in acute (both inpatient and outpatient) and primary care for patients known to have
diabetes and for those who may develop steroid induced diabetes as defined below.
Steroid induced diabetes is defined as a blood glucose > 12 mmol/L on two occasions in a 24 hour period.
Steroid use is defined as glucocorticoid therapy (> 20mg prednisolone or equivalent – see table 1 below) for
greater than 14 days.
Table 1: Steroid Dose Equivalents
Prednisolone 20mg daily approximately equivalent to:
Hydrocortisone 80mg
Dexamethasone 3mg
Methylprednisolone 16mg
Betamethasone 3mg
N.B. potency relates to anti-inflammatory action, which may not equate to hyperglycaemic effect.
NEED FOR A GUIDELINE
The prevalence of long term steroid use is estimated at 0.78% nationally and rising. Multiple observational
and retrospective data sets suggest an incidence of steroid induced diabetes of 18-52%.
There is a risk of the development of hyperosmolar hyperglycaemic state (HHS) or diabetic ketoacidosis (DKA)
in the context of steroid use. These are potentially avoidable complications with associated morbidity and
mortality.
Adherence to this guidance should:-
improve patient safety by preventing patients being admitted to secondary care with the above
diabetes emergencies;
improve potential outcomes in terms of morbidity and mortality;
minimise patients experiencing unnecessary osmotic symptoms due to hyperglycaemia.
Diabetes MCN Management of Diabetes Last updated: 28/06/2019 Approved by MSDTC: 26/06/2019 Risk with High Dose Steroids 2019 V1.0 Review due: 26/06/2021
RECOMMENDATIONS FOR SCREENING AND MONITORING FOR STEROID INDUCED DIABETES
Will the patient be taking high dose
steroids (Prednisolone > 20mg or
equivalent) for 2 weeks or more?
NO No monitoring required, advise patient of symptoms
(Appendix 1)
YES
Is patient known to have diabetes?
NO YES
Patient to be taught blood glucose monitoring (if not doing already). (This should be done by the practice nurse, Diabetes Centre or inpatient diabetes specialist nurse (DSN) – see notes below)
Blood glucose monitoring For patients requiring to be taught blood glucose monitoring at the Diabetes Centre, please call 01592 648001.
Patients not known to have diabetes should test blood glucose once daily before evening meals for the first 2 weeks of steroid use and record results (appendix 2).
If results are more than 12 mmol/L on 2 consecutive occasions, increase testing to 4 times daily pre meals and consider commencing treatment as per guidance.
If results are all less than 10mmol/L after 2 weeks, change frequency of testing to once per week while taking steroids.
(Test strips should be prescribed acutely then removed once steroid course complete).
Patients known to have diabetes should test 4 times daily pre-meals. The need to continue blood glucose monitoring should be individually assessed once steroid course complete.
Inpatients
Follow above guidance for blood glucose monitoring frequency.
Follow algorithm for treatment guidance.
Advise patient to arrange follow-up with practice nurse or to keep in contact with the DSN if they attend secondary care for their diabetes care.
For inpatients requiring to be taught blood glucose monitoring please call the Inpatient DSN on extension 21364 (please note the DSN will then arrange for the patient to be seen – this may not be on the same day of referral).
Diabetes MCN Management of Diabetes Last updated: 28/06/2019 Approved by MSDTC: 26/06/2019 Risk with High Dose Steroids 2019 V1.0 Review due: 26/06/2021
TREATMENT ALGORITHM
Patients should be equipped with home blood glucose monitoring and relevant education regarding hypoglycaemia management and driving responsibilities. This is due to the hypoglycaemia risk associated with sulphonylureas (SU) and insulin. Treatment should be tailored on an individual patient basis. This may require the local diabetes service to advise. The standard blood glucose target goal is 6-12 mmol/L.. Patients who are elderly, frail, palliative care, end of life, at risk of falling, eating variably or with impaired hypoglycaemia awareness will require a higher target (8-20 mmol/L). The aim for these patients is to avoid hypoglycaemia and symptomatic hyperglycaemia.
Patients without known DM
Known T2DM not on insulin
Known T2DM on insulin
If on once daily insulin in the evening , change injection to morning and titrate by 10-20% every 2-3 days according to pre-evening meal blood glucose level. If targets are not met consider Humalog 4 units with each meal and titrate by 10-20% every 2-3 days. If on twice daily insulin titrate
morning dose by 10-20% every
2-3 days according to pre-
evening meal blood glucose
level
If on basal bolus insulin titrate
short acting insulin by 10-20%
every 2-3 days
If targets not met titrate Gliclazide rapidly (increments of 40mg every
2-3 days) to a maximum of 240mg in the morning
If targets not met add in Humulin I or Insulatard 10 units in the morning
and titrate by 10-20% every 2-3 days according to pre-evening meal
blood glucose level
If targets not met consider Humalog 4 units with meals and titrate by 10 -
20% every 2-3 days and stop SU (local diabetes service may need to
advise)
Patients on insulin pumps – refer to the Diabetes Centre.
Patients with type 1 diabetes – remind to check ketones if blood glucose > 14 mmol/L and correct if ketones > 0.6 mmol/L.
Blood glucose > 12mmol/L on 2 occasions in 24 hours – consider Gliclazide 40mg in the morning
If no evidence of hyperglycaemia and not on an SU - consider Gliclazide 40mg in the morning. If already on SU - progress to titration if required.
Diabetes MCN Management of Diabetes Last updated: 28/06/2019 Approved by MSDTC: 26/06/2019 Risk with High Dose Steroids 2019 V1.0 Review due: 26/06/2021
TREATMENT WITHDRAWAL AND FOLLOW-UP
TREATMENT WITHDRAWAL
Gradual reduction in insulin or sulphonylurea (SU) therapy will be required during withdrawal of steroids. This
should be guided by blood glucose monitoring results with particular emphasis on avoidance of hypoglycaemia.
This may require the local diabetes service to advise. (For outpatient advice – contact Diabetes Centre, extension
28001 or 01592 648001).
REDUCING SU
When steroids are reduced it is recommended that SU is reduced by 40mg or 80mg in order to prevent
hypoglycaemia. Dose reduction will depend on patient’s blood glucose levels and SU dose at the time.
REDUCING INSULIN
When steroids are reduced it is recommended that insulin is reduced by 10-20% in order to prevent
hypoglycaemia. Percentage reduction will depend on patient’s blood glucose levels and insulin dose at the time.
NOTE
For some patients SU or insulin may need to be increased despite reduction in steroid dose. This will depend on
patient’s blood glucose levels at the time.
FOLLOW UP
Not known to have diabetes
Patients should continue to monitor blood glucose levels for 2 weeks once steroid course completed to ensure
blood glucose levels return to normal range (4-7 mmol/L).
If blood glucose levels remain elevated post steroids and HbA1c pre-steroid treatment is <48 mmol/mol, patient
should have an oral glucose tolerance test done in primary care 6 weeks post completion of steroid course
Steroid induced diabetes
If blood glucose levels remain elevated post steroids and HbA1c pre-steroid treatment is >48 mmol/mol, patient
should be treated as new diagnosis of type 2 diabetes and treatment initiated as required.
Known to have diabetes
Routine follow up in usual care setting
For inpatients
Contact the inpatient DSN on extension 21364 for advice as required
Diabetes MCN Management of Diabetes Last updated: 28/06/2019 Approved by MSDTC: 26/06/2019 Risk with High Dose Steroids 2019 V1.0 Review due: 26/06/2021
Appendix 1: Patient information leaflet – Glucose Monitoring For Those Not Known To Have Diabetes
Dear ……………….
Start Date: ...............................
Taking steroid medication can lead to a rise in blood glucose levels which may need to be treated.
Therefore, it is important that you regularly monitor your blood glucose levels.
Please measure your blood glucose levels once daily before your evening meal for the first 2 weeks
of steroid use and complete the table below.
Week 1
DATE
TIME
READING
Week 2
DATE
TIME
READING
If your blood glucose level is greater than 12 mmol/L on 2 consecutive occasions, increase
testing to 4 times daily (before main meals and bed time) and make an appointment with your
practice nurse.
If your blood glucose levels are all less than 12 mmol/L after 2 weeks you can reduce
monitoring to once per week while taking the steroid medication.
If your blood glucose level is over 20 mmol/L and you feel unwell contact your GP surgery or
call NHS 24 (dial 111) for advice out-of-hours.
Additional blood glucose level readings can be recorded here.
DATE
TIME
READING
Diabetes MCN Management of Diabetes Last updated: 28/06/2019 Approved by MSDTC: 26/06/2019 Risk with High Dose Steroids 2019 V1.0 Review due: 26/06/2021
REFERENCES
1. Joint British Diabetes Societies for inpatient care. Management of Hyperglycaemia and Steroid (Glucocorticoid) Therapy, 2014.
2. Umpierrez, G.E., et al., Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab, 2012. 97(1): p. 16-38.
3. Clement, S., et al., Management of diabetes and hyperglycemia in hospitals. Diabetes Care, 2004. 27(2): p. 553-91.
4. Liu, X.X., et al., Hyperglycemia induced by glucocorticoids in nondiabetic patients: a meta-analysis. Ann Nutr Metab, 2014. 65(4): p. 324-32.
5. Donihi, A.C., et al., Prevalence and predictors of corticosteroid-related hyperglycemia in hospitalized patients. Endocr Pract, 2006. 12(4): p. 358-62.
6. Clore, J.N. and L. Thurby-Hay, Glucocorticoid-induced hyperglycemia. Endocr Pract, 2009. 15(5): p. 469-74.
7. Ha, Y., et al., Glucocorticoid-induced diabetes mellitus in patients with systemic lupus erythematosus treated with high-dose glucocorticoid therapy. Lupus, 2011. 20(10): p. 1027-34.
8. Lee, S.Y., et al., Glucocorticoid-induced diabetes mellitus in patients with lymphoma treated with CHOP chemotherapy. Support Care Cancer, 2014. 22(5): p. 1385-90.
9. Iwamoto, T., et al., Steroid-induced diabetes mellitus and related risk factors in patients with neurologic diseases. Pharmacotherapy, 2004. 24(4): p. 508-14.
10. Hwang, J.L. and R.E. Weiss, Steroid-induced diabetes: a clinical and molecular approach to understanding and treatment. Diabetes Metab Res Rev, 2014. 30(2): p. 96-102.
11. Derr, R.L., V.C. Hsiao, and C.D. Saudek, Antecedent hyperglycemia is associated with an increased risk of neutropenic infections during bone marrow transplantation. Diabetes Care, 2008. 31(10): p. 1972-7.
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